Pharmacy Medical Necessity Guidelines

The Pharmacy Medical Necessity Guidelines below detail coverage criteria for Harvard Pilgrim Health Care and Tufts Health Plan lines of business. For certain lines of business, you’ll find the pharmacy guidelines elsewhere: Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, and Tufts Health One Care. You’ll also find information on Step Therapy guidelines on the Pharmacy Utilization Management page.

Tufts Health Together utilizes MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs. In addition, for One Care, certain anti-obesity drugs are covered under MassHealth. For drug coverage and criteria refer to the MassHealth Drug List.